STROKE MIMICS: A PSYCHOGENIC STROKE PATIENT TREATED WITH ALTEPLASE

2019 ◽  
Vol 17 (1) ◽  
pp. 97-102
Author(s):  
Dariusz Kotlęga ◽  
Barbara Peda ◽  
Tomasz Trochanowski ◽  
Monika Gołąb-Janowska ◽  
Sylwester Ciećwież ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Conversion Disorder ◽  
Initial Diagnosis ◽  
Therapeutic Window ◽  
Stroke Mimics ◽  
Conversion Disorders ◽  
Proper Diagnosis ◽  
Intravenous Alteplase ◽  
The Subject ◽  
Stroke Mimic

For rtPA treatment to be effective it should be initiated within the first 4.5 hours following the onset of a stroke. Such a short therapeutic window demands a rapid diagnosis and decision making on the part of the physician. There are patients with stroke-like symptoms and an initial diagnosis of a stroke, but who are finally diagnosed as suffering from another condition. According to the subject literature, stroke mimics are diagnosed in about 1.4 – 3.5% of patients initially diagnosed as having had an ischemic stroke. Psychogenic strokes (conversion disorders) may be found in as many as 8.2% of stroke patients. Proper diagnosis is especially important in patients eligible for thrombolytic treatment when there is usually not enough time to establish the diagnosis of a stroke mimic, especially one of psychogenic origin. A patient with an initial diagnosis of an ischemic stroke who was treated with intravenous alteplase infusion. The previous two ischemic strokes treated in the same manner had been diagnosed one and two years earlier. In all hospitalizations no rtPA treatment complications had been observed. In our patient a proper neuropsychological examination was performed and a conversion disorder diagnosed. We would like to underline the importance of cooperation between the neuropsychologist and neurology physician within clinical practice.

Abstract WP395: Can Nursing-driven Stroke Alert Activations be Effective?

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Nicole L Anderson ◽  
Amy L Castle ◽  
Ganesh Asaithambi
Keyword(s):  
Emergency Department ◽  
Acute Stroke ◽  
Treatment Delays ◽  
Stroke Mimics ◽  
Intravenous Alteplase ◽  
Stroke Mimic ◽  
High Level ◽  
The Impact

Background: Earlier stroke alert activations in the emergency department can assemble needed resources quickly in order to shorten treatment delays among eligible patients. We compared the impact of nursing-driven stroke alert activations to EMS- or physician-directed stroke alert activations. Methods: From January 2015 to June 2016, we reviewed data from all emergency department stroke alert activations at an acute stroke ready hospital. We compared nursing (RN)-driven to paramedic (EMS)- and physician (MD)-driven stroke alert activations to determine rates of stroke mimic diagnoses at discharge and use of intravenous alteplase as well as median door-to-stroke alert, door-to-CT, and door-to-needle times. Results: There were 175 stroke alert activations during the study period (42 RN, 87 pre-hospital, 46 MD). Stroke mimics prompting stroke alert activations were not significantly different between RN- and EMS-activations (26.2% RN vs 34.5% EMS, p=0.42) but was significantly higher for MD activations (50% MD, p=0.04). Compared to RN-activations, EMS-activations had shorter door to stroke alert (-7 [-10, -5] minutes EMS vs 4 [1, 7] minutes RN, p<0.01) and door to CT (0 minutes EMS vs 14 [8, 16] minutes RN, p<0.01) times; MD-activations had longer door to stroke alert (11.5 [6, 22] minutes MD, p<0.01) and door to CT (20.5 [14, 30.75] minutes MD, p<0.01). Door-to-needle times were similar between RN- and MD-activations (51 [38, 54] minutes RN vs 58 [49, 63] MD, p=0.25); there was a trend towards quicker DNTs for EMS-activations (39 [31, 43] minutes EMS, p=0.057). Rates of alteplase usage were similar for RN-activations (19%) compared to EMS- (12.6%, p=0.43) and MD- (23.9%, p>0.99) activations. Conclusion: Because of a high level of accuracy, nursing-driven stroke alert activations should be encouraged if indicated in order to shorten stroke alert time metrics when pre-hospital alerts have not occurred. Further studies are needed to examine the impact of nursing-driven stroke alert activations.

Telestroke consultation can accurately diagnose ischemic stroke mimics

2021 ◽  
pp. 1357633X2198955
Author(s):  
Jason T Poon ◽  
Aleksander Tkach ◽  
Adam H de Havenon ◽  
Knut Hoversten ◽  
Jaleen Johnson ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Predictive Value ◽  
Clinical Information ◽  
Excellent Correlation ◽  
Stroke Mimics ◽  
Intravenous Tissue Plasminogen Activator ◽  
The Us ◽  
Tissue Plasminogen ◽  
Stroke Mimic ◽  
Ischemic Attack

Introduction Telestroke (TS) networks are standard in many areas of the US. Despite TS systems having approximately 33% mimic rates, it is unknown if TS can accurately diagnose patients with acute ischemic stroke (AIS) versus stroke mimics. Methods We performed a retrospective review of consecutive TS consults to 27 TS sites in six states during 2018. Clinical information and diagnosis were extracted from discharge records and compared to those from the TS consult. Discharge diagnoses were verified and coded into 12 categories. Cases without a clear discharge diagnosis and intracerebral haemorrhage were excluded. We report agreement and a Cohen’s kappa between TS and discharge diagnoses for the category of AIS/transient ischemic attack (TIA) versus stroke mimic. Results We included 404 cases in the analysis (mean age 66 years; 54% women). Of these, 225 had a TS diagnosis of AIS/TIA; 102 (45%) received intravenous tissue plasminogen activator. Our study demonstrated a high diagnostic agreement for AIS/TIA (88%) with a kappa of 0.75 for stroke and mimics. Of the 179 patients diagnosed with a stroke mimic on TS, 27 (15%) were diagnosed with AIS/TA by discharge. TS mimic diagnosis had a positive predictive value (PPV) of 85% and a negative predictive value (NPV) of 90%; TS diagnosis of stroke/TIA had PPV 90%, NPV 85%. Discussion We found excellent correlation between TS and discharge diagnoses for patients with both stroke and stroke mimics. This suggests that TS systems can accurately assess a wider variety of patients with acute neurologic syndromes other than AIS.

scholarly journals External Validation of Stroke Mimic Prediction Scales in the Emergency Department

2020 ◽  
Author(s):  
Tian Ming Tu ◽  
Guan Zhong Tan ◽  
Seyed Ehsan Saffari ◽  
Chee Keong Wee ◽  
David Jeremiah Ming Siang Chee ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Decision Tree ◽  
Acute Ischemic Stroke ◽  
Univariate Analysis ◽  
Receiver Operating Curve ◽  
Emergency Setting ◽  
Predictive Values ◽  
Stroke Mimics ◽  
Prediction Tools ◽  
Stroke Mimic

Abstract Background Acute ischemic stroke is a time-sensitive emergency where accurate diagnosis is required promptly. Due to time pressures, stroke mimics, whom present with similar signs and symptoms as acute ischemic stroke, pose a diagnostic challenge to the emergency physician. With limited access to investigative tools, clinical prediction tools, based only on clinical features, may be useful to identify stroke mimics. We aim to externally validate the performance of 4 stroke mimic prediction scales and aim to derive a novel decision tree, to improve identification of stroke mimics. Methods We performed a retrospective cross-sectional study at a primary stroke centre, served by a telestroke hub. We included consecutive patients whom were administered intravenous thrombolysis for suspected acute ischemic stroke from January 2015 to October 2017. Four stroke mimic prediction tools (FABS, simplified FABS, Telestroke Mimic Score and Khan Score) were rated simultaneously, using only clinical information prior to administration of thrombolysis. The final diagnosis was ascertained by an independent stroke neurologist. Area under receiver operating curve (AUROC) analysis was performed. A classification tree analysis was also conducted using variables which were found to be significant in the univariate analysis. Results Telestroke Mimic Score had the highest discrimination for stroke mimics among the 4 scores tested (AUROC = 0.75, 95% CI = 0.63–0.87), although it was not statistically significantly better. Telestroke Mimic Score had the highest sensitivity (91.3%), while Khan score had the highest specificity (88.2%). All 4 scores had high positive predictive value (88.1–97.5%) and low negative predictive values (4.7–32.3%). A novel decision tree, using only age, presence of migraine and psychiatric history, had a higher prediction performance (AUROC = 0.80). Conclusion Four tested stroke mimic prediction scales performed similarly well to identify stroke mimics in the emergency setting. A novel decision tree may improve the identification of stroke mimics.

Abstract T P274: Stroke Mimics in Telestroke

Stroke ◽  
2014 ◽  
Vol 45 (suppl_1) ◽  
Author(s):  
Rayetta K Johnson
Keyword(s):  
Ischemic Stroke ◽  
Rural Communities ◽  
Complication Rate ◽  
Medical Center ◽  
Related Complication ◽  
Face To Face ◽  
Stroke Mimics ◽  
False Positive Diagnosis ◽  
Stroke Team ◽  
Stroke Mimic

Background and Issues: Wake Forest Baptist Medical Center in Winston-Salem, N.C. deployed a telestroke network system in January of 2010 to provide 24/7 access to a stroke specialist for rural communities. There are twelve hospitals in the network at the present time with tPA administration rate currently at 43%. The potential advantage of face-to-face examination is that it is potentially easier to identify stroke mimics. The frequency of false-positive diagnosis of ischemic stroke has been estimated at approximately 1-14%. It has been demonstrated that patients with mimics have a low tPA related complication rate but it is relevant that these patients have received an unnecessary and potentially harmful treatment. Methods: We reviewed the data on 436 patients who received telestroke consultations between 1/2010 and 9/2012. We retrieved information on the following: number of mimics, presenting complaints and clinical characteristics of patients and outcomes. Results: There were 49 drip and ship patients, with 14% of patients being diagnosed as stroke mimics. The percentage of stroke mimics given thrombolytic therapy via the telestroke network was low and is similar to what has been reported elsewhere. Our results concur with previous studies, proving the feasibility and safety of treating acute ischemic stroke via telemedicine. Even though the administration of tPA in the mimic patient has a low complication rate it provides an unnecessary (medically and financially) intervention and is a potentially harmful treatment. Our stroke team set forth a goal to decrease the rate of treating stroke mimic patients via our telestroke network. Two strategies were developed: first, an educational program was provided for each network hospital regarding neurological assessment and differential findings of ischemic stroke and a stroke mimic, and second, case studies of stroke mimic patients were presented and discussed at our quarterly telestroke conferences. These educational endeavors have decreased the number of stroke mimics that are treated with tPA via our telestroke network from 14% to 9%.

Abstract P281: Acute Stroke Mimics: Etiological Spectrum and Efficacy of Stroke Assessing Scores

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Kenneth Benjamin ◽  
A. T Prabhakar ◽  
K.P.P Abhilash ◽  
Vivek Mathew ◽  
Shaikh Atif Iqbal Ahmed ◽  
...  
Keyword(s):  
Acute Stroke ◽  
Univariate Analysis ◽  
Multivariate Logistic Regression Analysis ◽  
Therapeutic Window ◽  
Presenting Symptoms ◽  
Stroke Mimics ◽  
Number Of Patients ◽  
Speech Time ◽  
Etiological Spectrum ◽  
Stroke Mimic

Introduction: Stroke mimics constitute a good number of patients referred as acute strokes within the window period for acute therapies. Proper triaging can avoid unnecessary imaging and even thrombolytic therapies in these patients. This study looked at etiological spectrum of acute stroke mimics presenting within the 4.5 hours therapeutic window. We also evaluated the FAST (Face-Arm-Speech-Time), BEFAST (Balance -Eyes-Face-Arm-Speech-Time) and the ROSIER (Recognition of Stroke in the Emergency Room) tools in picking true strokes. Methods: A prospective observational cohort study over a 2- year period; A descriptive analysis of various etiologies presenting as acute stroke was done. The presenting symptoms, signs and the diagnostic value of the FAST, BEFAST, and the ROSIER Scores in both the stroke mimics and true strokes were noted and the sensitivity and specificity for picking up the stroke mimics were calculated. Student’s t test, univariate analysis and multivariate logistic regression analysis were done. Diagnosis of stroke was confirmed by MRI. Results: After initial screening by Neurologists, stroke mimics constituted 328/1635 (20%) of referrals for acute stroke. Focal and generalized seizures with transient weakness and peripheral vertigo were the most common acute stroke mimics; followed by metabolic causes and psychiatric disorders. Females were more in the stroke mimic group (p = 0.02). Ischemic heart disease and atherosclerotic risk factors (except diabetes mellitus) were significantly higher among true strokes. 4 (1.2%) of the stroke mimics were treated with IV thrombolysis. Diagnostic accuracy for different stroke differentiating tools were: FAST (Sensitivity 85,9% specificity 52.8% Odds 6.8), BEFAST (Sensitivity 97.0% specificity 31.4% Odds 14.9) And ROSIER Scale (Sensitivity 85.7% specificity 59.4% Odds 8.7%). In Conclusion, Stroke mimics can constitute up to 20% of cases evaluated as strokes. None of the triaging tools appear to have enough accuracy. A proper history and clinical examination should be given priority over fixed protocols whenever acute stroke mimic are suspected, especially before administering acute costly interventions. Auditing stroke mimics is important to improve acute stroke pathways.

Abstract WP301: Telestroke Consultation Can Accurately Diagnose Ischemic Stroke Mimics

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Jason T Poon ◽  
Aleksander Tkach ◽  
Adam H DeHavenon ◽  
Jaleen Smith ◽  
Peter M Hannon ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Clinical Information ◽  
Discharge Diagnosis ◽  
Excellent Correlation ◽  
Diagnostic Agreement ◽  
University Of Utah ◽  
Stroke Mimics ◽  
The Us ◽  
Stroke Mimic ◽  
The University

Introduction: Telestroke (TS) networks have become standard in many areas of the US, increasing thrombolysis rates in patients with acute ischemic stroke (AIS). By providing an early, accurate diagnosis, patients with stroke mimics may also benefit from TS consultation and avoid unnecessary treatments and transfers. However, despite TS systems having up to 50% mimic rates, it is unknown if TS can accurately diagnose patients with stroke vs stroke mimics. Methods: This was a retrospective review of consecutive TS consults at the University of Utah Hospital to 27 TS sites in 6 states from Jan-Dec 2018. Clinical information and diagnosis were extracted from discharge records and compared to those from the TS consult. Discharge diagnosis was determined by the discharging physician, recorded by the TS coordinator, and verified and coded into 12 categories by 2 physicians. Cases without a clear discharge diagnosis were excluded. When multiple TS diagnoses were listed without priority, the first one was used as the diagnosis. We report agreement and a Cohen’s kappa between TS and discharge diagnoses for the category of AIS/TIA versus stroke mimic. Results: We reviewed 476 TS cases (mean age 66 years; 54% women); 71 were excluded for lack of discharge diagnosis leaving 405 cases for analysis. Of these, there were 225 TS diagnoses of AIS/TIA; 102 (45%) received IV tPA. Our study demonstrated high diagnostic agreement for AIS/TIA (88%) with a kappa of 0.75 for stroke and mimics. Of the 180 patients diagnosed with a stroke mimic on TS, 27 (15%) were diagnosed with AIS/TA by discharge . (Figure 1 ). TS mimic diagnosis had a PPV of 85% and NPV of 90%; TS diagnosis of stroke/TIA had PPV 90%, NPV 85%. Only 3% of stroke mimics were transferred. Conclusion: The Utah TS system has excellent correlation between TS and discharge diagnoses for patients with both stroke and stroke mimics. This suggests that TS systems can accurately assess a wider variety of patients with acute neurologic syndromes other than AIS.

scholarly journals To tPA or Not to tPA: Two Medical-Legal Misadventures of Diagnosing a Cerebrovascular Accident as a Stroke Mimic

2019 ◽  
Vol 3 (3) ◽  
pp. 194-198
Author(s):  
Malia Moore ◽  
Jonathan Stuart ◽  
Alexandra Humphreys ◽  
James Pfaff
Keyword(s):  
Plasminogen Activator ◽  
Cerebrovascular Accident ◽  
Conversion Disorder ◽  
Family Interactions ◽  
Hemiplegic Migraine ◽  
Cerebrovascular Accidents ◽  
Stroke Mimics ◽  
Poor Patient ◽  
Tissue Plasminogen ◽  
Stroke Mimic

We present two recent successfully litigated malpractice cases in which patients with cerebrovascular accidents were misdiagnosed as stroke mimics. The first was diagnosed as a hemiplegic migraine, which occurs in only 0.01% of the population. The second was diagnosed as a conversion disorder, which ultimately has a neurologic etiology in 4% of cases. In both cases, issues of poor patient communication and poor documentation were paramount in the legal outcome. We discuss caveats of stroke mimics, tissue plasminogen activator administration liability, and pitfalls in patient and family interactions.

Acute Stroke Mimics: Etiological Spectrum and Efficacy of FAST, BE FAST, and the ROSIER Scores

2020 ◽  
Vol 3 (2) ◽  
pp. 151-158
Author(s):  
Sanjith Aaron ◽  
Prabhakar A. T. ◽  
Vivek Mathew ◽  
Lakshmanan Jeyaseelan ◽  
Kenneth Benjamin ◽  
...  
Keyword(s):  
Acute Stroke ◽  
Therapeutic Window ◽  
Stroke Mimics ◽  
Generalized Seizures ◽  
Number Of Patients ◽  
Stroke Team ◽  
Etiological Spectrum ◽  
Stroke Mimic ◽  
Good Number ◽  
Peripheral Vertigo

Background and Purpose: Stroke mimics constitute a good number of patients referred as acute strokes within the window period for acute therapies. Proper triaging can avoid unnecessary imaging and even thrombolytic therapies in these patients. This study looked at the etiological spectrum of acute stroke mimics presenting within the 4.5 hours therapeutic window. We also evaluated the FAST, BE FAST, and the ROSIER tools in picking true strokes. Methods: Prospective study conducted over a 2-year period. Results: Acute stroke mimics constituted 328/1635 (20%) of referrals for acute stroke after screening by the neurology stroke team. Focal and generalized seizures with transient weakness and peripheral vertigo were the commonest acute stroke mimics; followed by metabolic causes and psychiatric disorders. Females were more in the stroke mimic group ( P = .02). Ischemic heart disease and atherosclerotic risk factors (except diabetes mellitus) were significantly higher among true strokes. In total, 4 (1.2%) of the stroke mimics were treated with IV thrombolysis. Diagnostic accuracy for different stroke differentiating tools are as follows: FAST (sensitivity 85.9%, specificity 52.8%, odds 6.8), BE FAST (sensitivity 97.0%, specificity 31.4%, odds 14.9), and ROSIER scale (sensitivity 85.7%, specificity 59.4%, odds 8.7%). Conclusions: Acute stroke mimics can constitute up to 20% of cases evaluated as acute strokes by neurology stroke teams. None of the triaging tools appear to have enough accuracy. A proper history and clinical examination should be given priority over fixed protocols whenever acute stroke mimic are suspected especially before administering acute costly interventions. Auditing stroke mimics is important to improve acute stroke pathways.

scholarly journals Stroke-mimics in stroke-units. Evaluation after changes imposed by randomized trials

2020 ◽  
Vol 78 (2) ◽  
pp. 88-95
Author(s):  
Héloïse IFERGAN ◽  
Aymeric AMELOT ◽  
Mohammad ISMAIL ◽  
Marie GAUDRON ◽  
Jean-Philippe COTTIER ◽  
...  
Keyword(s):  
Acute Stroke ◽  
Emergency Services ◽  
Brain Lesion ◽  
Motor Impairment ◽  
Therapeutic Window ◽  
Acute Ischemia ◽  
Stroke Treatment ◽  
Stroke Mimics ◽  
Number Of Patients ◽  
Stroke Mimic

Abstract A larger therapeutic window for stroke treatment requires a significant change in the organization of emergency services, avoiding the increase in number of imaging exams and indirectly the time to treatment. Objective: To highlight the relation between faster clinical evaluation and stroke over-suspicion and consequently excessive imaging acquisition. To identify predictors of ischemic stroke and stroke mimics (SM), aiming for better patient selection for comprehensive neuroimaging and reperfusion therapies. Methods: Retrospective, cohort, observational, single-center study that reviewed all consecutive files of patients presenting with acute neurological symptoms who underwent CT scan or MRI from July 1, 2016 to July 1, 2017. Results: 736 patient files were reviewed. 385 patients (52.3%) presented with confirmed acute ischemic infarct, 93 (12.6%) had another brain lesion mimicking acute ischemia, and 258 (35.1%) had normal imaging. Acute stroke was more frequent in elderly patients with atrial fibrillation, arterial hypertension, or dysarthria or right motor impairment. Stroke mimic was associated with female patients with low vascular risk factors, low NIHSS, and patients with decreased level of consciousness or symptoms suggestive of posterior circulation. Discussion: 47.7% of all patients seen at the stroke unit did not have acute stroke lesions. Clinical assessment data have been used to provide indicators of acute stroke and stroke mimic patients, and symptoms corresponding to acute stroke and stroke mimic seem to be similar in the literature. Conclusion: Considering that the number of patients admitted for stroke treatment will increase even further with a larger therapeutic window for mechanical thrombectomy and for thrombolysis, a diagnostic decision-making algorithm for stroke patients is required in order to reinforce the suspicion of stroke indicating an urgent MRI.

Safety and predictors of stroke mimics in The Norwegian Tenecteplase Stroke Trial (NOR-TEST)

2018 ◽  
Vol 14 (5) ◽  
pp. 508-516 ◽  
Author(s):  
Christopher Elnan Kvistad ◽  
Vojtech Novotny ◽  
Halvor Næss ◽  
Guri Hagberg ◽  
Hege Ihle-Hansen ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Cerebral Ischemia ◽  
Transient Ischemic Attack ◽  
Sensory Loss ◽  
Stroke Mimics ◽  
Symptomatic Intracerebral Hemorrhage ◽  
Acute Cerebral Ischemia ◽  
Stroke Mimic ◽  
Ischemic Attack ◽  
Stroke Trial

Background Stroke mimics are frequently treated with thrombolysis in clinical practice and thrombolytic trials. Although alteplase in stroke mimics has proven to be safe, safety of tenecteplase in stroke mimics has not been assessed in an ischemic stroke study setting. We aimed to assess clinical characteristics and safety of stroke mimics treated with thrombolysis in the Norwegian Tenecteplase Stroke Trial. We also aimed to identify possible predictors of stroke mimics as compared to patients with acute cerebral ischemia. Methods Norwegian Tenecteplase Stroke Trial was a phase-3 trial investigating safety and efficacy of tenecteplase vs. alteplase in patients with suspected acute cerebral ischemia. Two groups were defined based on diagnose at discharge: patients with a different diagnose than ischemic stroke or transient ischemic attack (stroke mimics group) and patients diagnosed with ischemic stroke or transient ischemic attack (acute cerebral ischemia group). Logistic regression analyses were performed with stroke mimics vs. acute cerebral ischemia as dependent variable to identify predictors of stroke mimics. Results Of 1091 randomized patients, 181 (16.6%) were stroke mimics. Migraine (22.2%) and peripheral vertigo (11.4%) were the two most frequent stroke mimic-diagnoses. There was no symptomatic intracerebral hemorrhage in the stroke mimics group. Stroke mimics were independently associated with age ≤60 years (OR 2.75, p < 0.001), female sex (OR 1.48, p = 0.026), no history of myocardial infarction (OR 2.03, p = 0.045), systolic BP ≤ 150 mmHg (OR 2.33, p < 0.001), NIHSS ≤ 6 points (OR 1.83, p = 0.011), sensory loss (OR 1.55, p = 0.015), and no facial paresis (OR 2.41, p < 0.001) on admission. Conclusion Thrombolysis with tenecteplase seems to be as safe as with alteplase in stroke mimics. Predictors were identified for stroke mimics which may contribute to differentiate stroke mimics from acute cerebral ischemia in future stroke trials.

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